Hospital Inpatient Quality Reporting Benchmarks and Trends

Transcription

Hospital Inpatient Quality Reporting
Benchmarks and Trends
Third Quarter 2011 through Third Quarter 2012
Benchmarks for Hospital-Abstracted Acute Myocardial Infarction (AMI) Data - Third Quarter 2012
Using the ABC Technique*
*The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures.
Benchmark Rate (%)
Numerator
(Benchmark)
Denominator
(Benchmark)
Number of
Hospitals
(Benchmark)
National Rate (%)
Numerator
(National)
Denominator
(National)
Number of
Hospitals
(National)
AMI-1: Aspirin at Arrival
100.0
11,740
11,742
61
99.3
115,432
116,200
3,053
AMI-2: Aspirin Prescribed at Discharge
100.0
10,539
10,541
57
99.2
104,196
105,069
2,930
AMI-3: ACEI or ARB for LVSD
99.9
1,904
1,906
52
97.7
17,341
17,754
2,194
AMI-5: Beta-Blocker at Discharge
100.0
10,355
10,356
60
99.0
99,070
100,055
2,892
AMI-7a: Fibrinolytic Therapy Received
Within 30 Minutes of Hospital Arrival
100.0
17
17
5
66.5
105
158
105
AMI-8a: Primary PCI Received within 90
Minutes of Hospital Arrival
100.0
1,557
1,557
64
95.2
14,257
14,974
1,570
AMI-10: Statin Prescribed at Discharge
100.0
10,341
10,346
65
98.1
99,692
101,617
2,916
Performance Measure Name
*Benchmark Rate(%) is calculated using the Top 10% Sample.
*National Rate(%) is calculated using the 100% Eligible Sample.
*ACEI = Angiotensin Converting Enzyme Inhibitor
*ARB = Angiotensin Receptor Blocker
*LVSD = Left Ventricular Systolic Dysfunction
*PCI = Percutaneous Coronary Intervention
*Selected references
1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998, vol 10 (5): 443-447.
2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269-281.
3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 61-65.
4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE). University of Alabama at
Birmingham.
The benchmarks of care can be found on QualityNet at:
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228768205297
This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development Special
Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect
CMS policy. 10SOW-SPOK01-1673-OK-0513
HIQR Benchmarks and Trends - 3Q2012
Date Completed: May 15, 2013
Page 1 of 13
Trends of Acute Myocardial Infarction (AMI) Performance Measures and Benchmarks
from Third Quarter 2011 to Third Quarter 2012
AMI-2: Aspirin Prescribed at
Discharge
Qtr 3 2011
Benchmark
Rate (%)
100.0
Qtr 3 2011
National
Rate (%)
99.2
Qtr 4 2011
Benchmark
Rate (%)
100.0
Qtr 4 2011
National
Rate (%)
99.2
Qtr 1 2012
Benchmark
Rate (%)
100.0
Qtr 1 2012
National
Rate (%)
99.2
Qtr 2 2012
Benchmark
Rate (%)
100.0
Qtr 2 2012
National
Rate (%)
99.3
Qtr 3 2012
Benchmark
Rate (%)
100.0
Qtr 3 2012
National
Rate (%)
99.3
100.0
99.0
100.0
99.1
100.0
99.1
100.0
99.1
100.0
99.2
AMI-5: Beta-Blocker Prescribed
at Discharge
99.9
97.3
99.9
97.7
100.0
97.6
99.9
97.5
99.9
97.7
100.0
98.9
100.0
98.9
100.0
98.9
100.0
99.0
100.0
99.0
AMI-7a: Fibrinolytic Therapy
Received Within 30 Minutes of
Hospital Arrival
100.0
62.6
100.0
55.4
100.0
58.8
100.0
65.3
100.0
66.5
99.9
93.9
99.9
94.4
99.9
94.6
99.9
95.1
100.0
95.2
100.0
97.5
100.0
97.6
99.9
97.8
100.0
98.0
100.0
98.1
AMI-8a: Primary PCI Received
within 90 Minutes of Hospital
Arrival
AMI-10: Statin Prescribed at
Discharge
The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national rates and the dark red lines with square points (■) represent the
benchmarks.
AMI-2: Aspirin Prescribed at Discharge
100.0
100.0
100.0
95.0
95.0
95.0
90.0
90.0
90.0
85.0
85.0
85.0
80.0
80.0
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Qtr 3
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
AMI-8a: Primary PCI Received Within 90
Minutes of Hospital Arrival
AMI-7a: Fibrinolytic Therapy Received
Within 30 Minutes of Hospital Arrival
100.0
90.0
80.0
70.0
60.0
50.0
Qtr 4
2011
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
100.0
95.0
90.0
90.0
85.0
85.0
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
95.0
90.0
85.0
80.0
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
AMI-10: Statin Prescribed at Discharge
95.0
Qtr 3
2011
100.0
Qtr 3
2011
100.0
80.0
AMI-5: Beta-blocker Prescribed at
Discharge
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
*PCI = Percutaneous Coronary Intervention
*Qtr = Quarter
Page 2 of 13
Benchmarks for Hospital-Abstracted Heart Failure (HF) Data - Third Quarter 2012
Benchmark
Rate (%)
Numerator
(Benchmark)
Denominator
(Benchmark)
Number of
Hospitals
(Benchmark)
National
Rate (%)
Numerator
(National)
Denominator
(National)
Number of
Hospitals
(National)
HF-1: Discharge Instructions
99.9
13,777
13,792
127
93.6
124,080
132,622
3,988
HF-2: Evaluation of LVS Function
100.0
16,869
16,869
80
98.8
162,893
164,875
4,094
HF-3: ACEI or ARB for LVSD
99.9
5,152
5,155
84
96.6
48,775
50,471
3,533
*LVS = Left Ventricular Systolic
1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care
1998, vol 10 (5): 443-447.
2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269281.
3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 6165.
4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education
(COERE). University of Alabama at Birmingham.
This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the
Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513
Page 3 of 13
Trends of Heart Failure (HF) Performance Measures and Benchmarks
Qtr 3 2011
Benchmark
Rate (%)
Qtr 3 2011
National
Rate (%)
Qtr 4 2011
Benchmark
Rate (%)
Qtr 4 2011
National
Rate (%)
Qtr 1 2012
Benchmark
Rate (%)
Qtr 1 2012
National
Rate (%)
Qtr 2 2012
Benchmark
Rate (%)
Qtr 2 2012
National
Rate (%)
Qtr 3 2012
Benchmark
Rate (%)
Qtr 3 2012
National
Rate (%)
99.9
92.6
99.9
92.7
99.9
93.1
99.9
93.3
99.9
93.6
100.0
98.6
100.0
98.7
100.0
98.7
100.0
98.7
100.0
98.8
99.9
96.3
100.0
96.5
100.0
96.4
99.9
96.5
99.9
96.6
The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national rates and the dark red lines with square points (■) represent the
benchmarks.
100.0
100.0
100.0
95.0
95.0
95.0
90.0
90.0
90.0
85.0
85.0
85.0
80.0
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
*LVSD = Left Ventricular Systolic
*Qtr = Quarter
Page 4 of 13
Benchmarks for Hospital-Abstracted Pneumonia (PN) Data - Third Quarter 2012
Benchmark
Rate (%)
Numerator
(Benchmark)
Denominator
(Benchmark)
Number of
Hospitals
(Benchmark)
National
Rate (%)
Numerator
(National)
Denominator
(National)
Number of
Hospitals
(National)
100.0
2,443
2,444
76
97.8
23,026
23,546
3,012
99.9
11,134
11,145
121
97.5
107,264
109,960
3,981
99.8
6,750
6,761
149
95.0
63,008
66,299
4,083
PN-3a: Blood Cultures Performed
Within 24 Hours to or 24 Hours After
Hospital Arrival for Patients Who Were
Transferred or Admitted to the ICU
Within 24 Hours of Hospital Arrival
PN-3b: Blood Cultures Performed in the
Emergency Department Prior to Initial
Antibiotic Received in Hospital
PN-6: Initial Antibiotic Selection for CAP
in Immunocompetent Patient
*ICU = Intensive Care Unit
*CAP = Community Acquired Pneumonia
1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998,
vol 10 (5): 443-447.
4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE).
University of Alabama at Birmingham.
This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development
Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not
necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513
Page 5 of 13
Trends of Pneumonia (PN) Performance Measures and Benchmarks
Qtr 3 2011
Benchmark
Rate (%)
Qtr 3 2011
National
Rate (%)
Qtr 4 2011
Benchmark
Rate (%)
Qtr 4 2011
National
Rate (%)
Qtr 1 2012
Benchmark
Rate (%)
Qtr 1 2012
National
Rate (%)
Qtr 2 2012
Benchmark
Rate (%)
Qtr 2 2012
National
Rate (%)
Qtr 3 2012
Benchmark
Rate (%)
Qtr 3 2012
National
Rate (%)
PN-3a: Blood Cultures Performed
Within 24 Hours to or 24 Hours After
Hospital Arrival for Patients Who Were
Transferred or Admitted to the ICU
Within 24 Hours of Hospital Arrival
99.9
97.3
100.0
97.5
99.9
97.6
100.0
97.7
100.0
97.8
PN-3b: Blood Cultures Performed in
the Emergency Department Prior to
Initial Antibiotic Received in Hospital
99.9
97.1
99.9
97.0
99.9
97.3
99.9
97.5
99.9
97.5
PN-6: Initial Antibiotic Selection for
CAP in Immunocompetent Patient
99.8
94.8
99.7
94.6
99.8
94.8
99.8
95.1
99.8
95.0
The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national rates and the dark red lines with square points (■) represent the benchmarks.
PN-3a: Blood Cultures Performed Within 24
Hours to or 24 Hours After Hospital Arrival for
Patients Who Were Transferred or Admitted to
the ICU Within 24 Hours of Hospital Arrival
100.0
PN-3b: Blood Cultures Performed in the
Emergency Department Prior to Initial
Antibiotic Received in Hospital
100.0
95.0
95.0
90.0
90.0
85.0
85.0
80.0
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
PN-6: Initial Antibiotic Selection for CAP
in Immunocompetent Patient
100.0
98.0
96.0
94.0
92.0
90.0
88.0
86.0
84.0
82.0
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
*ICU = Intensive Care Unit
*CAP = Community Acquired Pneumonia
*Qtr = Quarter
Page 6 of 13
Benchmarks for Hospital-Abstracted Surgical Care Improvement Project (SCIP) Data - Third Quarter 2012
Benchmark
Rate (%)
Numerator
(Benchmark)
Denominator
(Benchmark)
Number of
Hospitals
(Benchmark)
National
Rate (%)
Numerator
(National)
Denominator
(National)
Number of
Hospitals
(National)
SCIP-Inf-1: Prophylactic Antibiotic Received
Within One Hour Prior to Surgical Incision
99.9
25,478
25,498
100
98.5
248,678
252,377
3,539
SCIP-Inf-2: Prophylactic Antibiotic Selection for
Surgical Patients
99.9
25,203
25,222
105
98.9
248,959
251,853
3,538
SCIP-Inf-3: Prophylactic Antibiotics Discontinued
within 24 Hours After Surgery End Time
99.9
24,552
24,585
140
97.6
238,217
244,186
3,535
SCIP-Inf-4: Cardiac Surgery Patients With
Controlled 6 AM Postoperative Blood Glucose
SCIP-Inf-6: Surgery Patients with Appropriate
Hair Removal
99.7
4,113
4,127
47
96.5
39,452
40,883
1,164
100.0
37,032
37,034
70
99.8
363,847
364,577
3,525
SCIP-Inf-9: Urinary catheter removed on
Postoperative Day 1 (POD 1) or Postoperative
Day 2 (POD 2) with day of surgery being day zero
99.8
19,913
19,948
103
96.3
191,122
198,422
3,461
SCIP-Inf-10: Surgery Patients with Perioperative
Temperature Management
100.0
33,443
33,447
71
99.7
333,168
334,147
3,610
SCIP-CARD-2: Surgery Patients on Beta-Blocker
Therapy Prior to Arrival Who Received a BetaBlocker During the Perioperative Period
99.9
11,470
11,480
92
97.3
111,064
114,201
3,375
SCIP-VTE-1: Surgery Patients with
Recommended Venous Thromboembolism
Prophylaxis Ordered
99.9
27,446
27,466
102
98.4
269,781
274,274
3,592
SCIP-VTE-2: Surgery Patients Who Received
Appropriate Venous Thromboembolism
Prophylaxis within 24 Hours Prior to Surgery to 24
Hours After Surgery
99.9
27,741
27,760
138
97.7
267,653
273,941
3,587
1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998,
vol 10 (5): 443-447.
4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE). University of
Alabama at Birmingham.
This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development
Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not
necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513
Page 7 of 13
Trends of Surgical Care Improvement Project (SCIP) Performance Measures and Benchmarks
Qtr 3 2011
Benchmark
Rate (%)
Qtr 3 2011
National
Rate (%)
Qtr 4 2011
Benchmark
Rate (%)
Qtr 4 2011
National
Rate (%)
Qtr 1 2012
Benchmark
Rate (%)
Qtr 1 2012
National
Rate (%)
Qtr 2 2012
Benchmark
Rate (%)
Qtr 2 2012
National
Rate (%)
Qtr 3 2012
Benchmark
Rate (%)
Qtr 3 2012
National
Rate (%)
SCIP-Inf-1: Prophylactic Antibiotic
Received Within One Hour Prior to
Surgical Incision
99.9
98.1
99.9
98.2
99.9
98.4
99.9
98.5
99.9
98.5
Selection for Surgical Patients
99.9
98.4
99.9
98.6
99.9
98.7
99.9
98.7
99.9
98.9
SCIP-Inf-3: Prophylactic Antibiotics
Discontinued within 24 Hours After
Surgery End Time
99.9
97.0
99.8
97.2
99.9
97.5
99.8
97.5
99.9
97.6
SCIP-Inf-4: Cardiac Surgery Patients
With Controlled 6 AM Postoperative
Blood Glucose
SCIP-Inf-6: Surgery Patients with
Appropriate Hair Removal
99.8
95.3
99.8
95.7
99.9
96.2
99.8
96.3
99.7
96.5
100.0
99.8
100.0
99.8
100.0
99.8
100.0
99.8
100.0
99.8
SCIP-Inf-9: Urinary catheter removed
on Postoperative Day 1 (POD 1) or
Postoperative Day 2 (POD 2) with day
of surgery being day zero
99.8
94.5
99.8
95.2
99.9
95.5
99.9
96.0
99.8
96.3
Perioperative Temperature
Management
100.0
99.5
100.0
99.7
100.0
99.7
100.0
99.7
100.0
99.7
SCIP-CARD-2: Surgery Patients on
Beta-Blocker Therapy Prior to Arrival
Who Received a Beta-Blocker During
the Perioperative Period
99.9
96.4
99.9
96.8
99.8
96.5
99.9
97.0
99.9
97.3
Recommended Venous
Thromboembolism Prophylaxis
Ordered
99.9
97.9
99.9
98.1
99.9
98.2
99.9
98.3
99.9
98.4
SCIP-VTE-2: Surgery Patients Who
Received Appropriate Venous
Thromboembolism Prophylaxis within
24 Hours Prior to Surgery to 24 Hours
After Surgery
99.9
97.1
99.9
97.3
99.9
97.6
99.9
97.7
99.9
97.7
Received Within One Hour Prior to Surgical
Incision
100.0
95.0
90.0
85.0
80.0
Selection for Surgical Patients
100.0
100.0
95.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
SCIP-Inf-3: Prophylactic Antibiotics
Discontinued within 24 Hours After Surgery
End Time
100.0
95.0
90.0
95.0
90.0
90.0
85.0
85.0
85.0
80.0
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
SCIP-Inf-4: Cardiac Surgery Patients
With Controlled 6 AM Postoperative
Blood Glucose
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Graphs of SCIP trends continue on the following page.
Page 8 of 13
Graphs of SCIP trends (continued)
SCIP-Inf-9: Urinary catheter removed on
Postoperative Day 1 (POD 1) or
Postoperative Day 2 (POD 2) with day of
surgery being day zero
Appropriate Hair Removal
100.0
100.0
95.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Qtr 3
2011
85.0
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
SCIP-VTE-2: Surgery Patients Who Received
Appropriate Venous Thromboembolism
Prophylaxis within 24 Hours Prior to Surgery
to 24 Hours After Surgery
Recommended Venous Thromboembolism
Prophylaxis Ordered
100.0
90.0
80.0
80.0
SCIP-CARD-2: Surgery Patients on BetaBlocker Therapy Prior to Arrival Who
Received a Beta-Blocker During the
Perioperative Period
95.0
85.0
85.0
80.0
100.0
90.0
90.0
85.0
100.0
95.0
95.0
90.0
Perioperative Temperature Management
100.0
95.0
95.0
90.0
90.0
85.0
85.0
80.0
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
*Abx = antibiotics
*VTE = Venous Thromboembolism
*Qtr = Quarter
Page 9 of 13
Benchmarks for Hospital-Abstracted Immunization (IMM) Data - Third Quarter 2012
IMM1-a: Pneumococcal
Immunization - Overall Rate
IMM-2: Influenza Immunization**
Benchmark
Rate (%)
Numerator
(Benchmark)
Denominator
(Benchmark)
Number of
Hospitals
(Benchmark)
99.7
NA
49,223
NA
49,392
NA
325
NA
National
Rate (%)
88.7
NA
Numerator
(National)
436,130
NA
Number of
Denominator
Hospitals
(National)
(National)
491,660
NA
3,690
NA
Benchmark Rate(%) is calculated using the Top 10% Sample.
National Rate(%) is calculated using the 100% Eligible Sample.
**NA = Data not reported during this quarter (See algorithm)
1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for
Quality in Health Care 1998, vol 10 (5): 443-447.
2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical
Practice 1999, vol 5 (3): 269-281.
3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public
Health 1999, vol 89 (1): 61-65.
4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and
Education (COERE). University of Alabama at Birmingham.
This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under
the Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513
Page 10 of 13
Trends of Immunization (IMM) Performance Measures and Benchmarks
Third Quarter 2011 toThird Quarter 2012
Values displayed are in minutes (smaller values are better performing)
Qtr 3 2011
Benchmark
Rate (%)
Qtr 1 2012
Benchmark
Rate (%)
Qtr 1 2012
National
Rate (%)
Qtr 2 2012
Benchmark
Rate (%)
Qtr 2 2012
National
Rate (%)
Qtr 3 2012
Benchmark
Rate (%)
Qtr 3 2012
National
Rate (%)
IMM1-a: Pneumococcal Immunization Overall Rate
99.2
88.1
99.5
88.3
99.7
88.7
99.0
86.0
Qtr 3 2011
National
Rate (%)
Qtr 4 2011
Benchmark
Rate (%)
Qtr 4 2011
National
Rate (%)
IMM1-a: Pneumococcal Immunization Overall Rate
100.0
100.0
95.0
95.0
90.0
90.0
85.0
85.0
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
80.0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Note: Each quarter consists of 3 months of data.
*Qtr = Quarter
**Data not reported for IMM-2 during this quarter (See algorithm)
Page 11 of 13
Trends of Emergency Department (ED) Performance Measures and Benchmarks
Provider Median Time Data - Third Quarter 2011 to Third Quarter 2012
Values displayed are in minutes (smaller values are better performing)
Qtr 3 2011
Benchmark
Rate (%)
Qtr 1 2012
Benchmark
Rate (%)
Qtr 1 2012
National
Rate (%)
Qtr 2 2012
Benchmark
Rate (%)
Qtr 2 2012
National
Rate (%)
Qtr 3 2012
Benchmark
Rate (%)
Qtr 3 2012
National
Rate (%)
ED-1b: Median Time from ED
Arrival to ED Departure for
Admitted ED Patients - Reporting
Measure
260
175
256
176
257
178
ED-2b: Admit Decision Time to ED
Departure Time for Admitted
Patients - Reporting Measure
87
43
84
42
85
43
Qtr 3 2011
National
Rate (%)
Qtr 4 2011
Benchmark
Rate (%)
Qtr 4 2011
National
Rate (%)
The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national median and the dark red lines with square points (■) represent the
national top 10 percentile.
300
250
200
150
100
50
0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Mediann Time (mins)
Median Time (mins)
ED-1b: Median Time from ED Arrival to ED
Departure for Admitted ED Patients Reporting Measure
100
ED-2b: Admit Decision Time to ED Departure
Time for Admitted Patients - Reporting
Measure
80
60
40
20
0
Qtr 3
2011
Qtr 4
2011
Qtr 1
2012
Qtr 2
2012
Qtr 3
2012
Note: Each quarter consists of 3 months of data.
*Qtr = Quarter
Page 12 of 13
Appropriate Care Measure (ACM) Benchmarks - Third Quarter 2012
for Hospital Abstracted Data – PPS Only
Using the “ABC” Technique*
Benchmark
Rate (%)
Numerator
(Benchmark)
Denominator
(Benchmark)
Number of
Hospitals
(Benchmark)
National Rate
(%)
Numerator
(National)
Denominator
(National)
Number of
Hospitals
(National)
ACM for seven AMI HIQR measures
99.9
12,232
12,247
93
96.1
117,025
121,754
2,863
ACM for three HF HIQR measures
99.9
16,096
16,110
142
93.6
150,373
160,636
3,162
ACM for three PN HIQR measures
99.9
12,213
12,231
157
95.6
116,864
122,224
3,168
ACM for ten SCIP HIQR measures
99.2
36,928
37,217
246
92.3
343,473
372,057
3,175
ACM for one IMM HIQR measure
99.7
47,229
47,393
306
88.8
417,757
470,423
3,341
ACM for all 24 HIQR measures
98.8
123,900
125,439
316
91.9
1,145,492
1,247,094
3,399
Note: 24 RHQDAPU include: HF-1, HF-2, HF-3, AMI-1, AMI-2, AMI-3, AMI-5, AMI-7a, AMI-8a, AMI-10, PN-3a, PN-3b, PN-6, SCIP-1, SCIP-2, SCIP-3, SCIP-4, SCIP-6, SCIP-CARD2, SCIPVTE1, SCIP-VTE2, SCIP-9, SCIP-10, IMM-1a.
1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care
1998, vol 10 (5): 443-447.
2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269281.
3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 6165.
4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education
(COERE). University of Alabama at Birmingham.
This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the
Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513
Page 13 of 13

Hospital Inpatient Quality Reporting Benchmarks and Trends

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